Provider Demographics
NPI:1033254990
Name:ANDERSON, JENNIFER DIANE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DIANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6426 BENT TREE CIR.
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402
Mailing Address - Country:US
Mailing Address - Phone:505-324-8353
Mailing Address - Fax:505-324-8353
Practice Address - Street 1:380 CANYONVIEW DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8630
Practice Address - Country:US
Practice Address - Phone:505-324-0542
Practice Address - Fax:505-324-0542
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1649225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist